DRAFT -- USM REQUEST FOR TUITION REMISSION--Upon obtaining departmental authorization, this application must be presented for approval to the Human Resources/Personnel Office of the employee's home institution. A new application must be completed for each semester/session. If the employee is registering at multiple institutions, a separate application must be completed for each institution.

1. Academic Year: 20_____
Semester for which tuition remission is requested (enrollment term) □ Fall □ Winter □ Spring □ Summer ____ (include summer session # if institution has more than one Summer Session) □ Other ______
2. Employee Name: (Last Name, First Name) / 10. Student Name: (Last Name, First Name - if employee is student, leave blank)
3. Employee SSN: / 11. Student SSN:
4. Employee Original Date of Hire or Reinstatement
Month/Day/Year ____/____/____
Is your hire/reinstatement date on or after 1/1/90? Yes___ No___. / 12. Student is Employee's
□ Spouse □ Dependent
If hired on or after 1/1/90, spouse/dependents are eligible for tuition remission only toward a first undergraduate degree.
5. Complete if employee is retired or deceased:
□ Retired Month/Day/Year
□ Deceased ____/____/____ / 13. Student's Date of Birth: (Required for a dependent child - if employee or spouse of employee, leave blank)
Month/Day/Year ____/____/____

6. Active Employee is Employed: □ Full time □ Part time

Enter % employed if less than full time ______%
Retired or deceased employee was employed:

□ Full time □ Part time

Enter % employed if less than full time ______%

/ 14. Student Enrollment Status:
□ Undergraduate □ Freshman □ Sophomore
□ Junior □ Senior
□ Graduate
7. Employee Status:
□ Non-Exempt □ Contingent II □ Grad. Asst.
□ Exempt □ Retiree □ Grad. Research Asst.
□ Faculty □ Fellow □ Grad. Teaching Asst. / 15. Academic Major: (student/spouse of employee must complete this section if employee began USM employment on or after 1/1/1990)
8. Employee Home Institution:
□ AES □ BCCC □ BSU □ CES □ CSU □ FSU
□ MSU □ SU □ STM □ TU □ UB □ UMB
□ UMBC □ UMBI □ UMCES □ UMCP □ UMES
□ UMUC □ USMO / 16. Campus where employee/student is taking classes:
□ BCCC □ BSU □ CSU □ FSU □ MSU
□ SU □ STM □ TU □ UB □ UMB
□ UMBC □ UMCP □ UMES □ UMUC
9.  Employee Campus Address: ______
Employee Campus Phone #: ______
Employee Campus Email Address: ______ / 17. Number of credit hours to be remitted: ______
List account number(s) from which employee is paid:
______
______
______
______
18. Institution transfer of funds: Yes_____ No_____

I hereby certify that:

1.  the information given above is accurate;

2.  if request for tuition remission is being made for spouse/dependent, that spouse/dependent is not a part-time (50% or more) or FT, regular employee of the

USM nor appointed as a graduate teaching or graduate research assistant, nor graduate fellow or non-stipend scholar;

3.  if request is being made for dependent child, he/she is financially dependent as that term is defined by the US Internal Revenue Service;

4.  for spouse or dependent child(ren), the amount of tuition remission will be noted on my paycheck stub and will be taxed if student is taking graduate courses.

If the employee’s tuition cost exceeds the IRC limit, it will also be taxed.

5.  I have read and understand the tuition remission policy and guidelines.

Signature of Employee:______Date: ______

Signature of Department Head/Designee: ______Date: ______

Signature of HR Rep. at home institution: ______Date: ______

USM Form-MW - Revised 8/12/04